Inspection on 12/12/05 for 33 Abbotswood

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

33 Abbotswood 30/08/07

33 Abbotswood 16/02/07

33 Abbotswood 25/08/05

33 Abbotswood 21/12/04

33 Abbotswood 01/07/04

33 Abbotswood 12/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Abbotswood (33) 33 Abbotswood Guildford Surrey GU1 1UZ Lead Inspector Christine Bowman Unannounced Inspection 12th December 2005 09:30 Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Abbotswood (33) Address 33 Abbotswood Guildford Surrey GU1 1UZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Four Seasons Trust Limited fourseasonstrust@yahoo.com Mr Paul Joseph Fitzroy Bennett Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2005 Brief Description of the Service: 33 Abbotswood, The Four Seasons Trust, is a large detached house developed to provide a good standard of accommodation for 4 adults with learning disabilities and epilepsy. It is set in a pleasant residential area of similar homes and situated close to Guilford town centre. All the service users bedrooms are on the 1st floor are single occupancy and have en-suite facilities. Staff accommodation is limited to a small room used for sleeping in and for storage of documents. The ground floor has a dining room, sitting room, utility room, kitchen and toilet. There are plans to redevelop the basement area to provide a new office and games room. There is a garden to the rear and side of the property and some off road parking. There is a multi-person vehicle to ensure residents have easy access to local community. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second for the year commencing in April 2005 and ending in March 2006 and took place over four and a half hours. This report should be read in conjunction with the previous report to gain a more complete description of the service. The clients were just about to leave on a Christmas shopping trip, and thanks is offered for their patience in waiting until the afternoon. All of the four clients were spoken with, and the manager and a member of the care staff team were interviewed. A tour of the premises was undertaken, policies, procedures and records were viewed, and client files were sampled. It was not possible to verify recruitment checks, or view the gas safety certificate because these documents were stored at the main office, the manager stated and access was not possible. The clients were friendly and chatted in a relaxed manner about their holidays, social, educational and work-related activities. They related well to each other and to the staff, who offered encouragement and a sense of fun. The clients laughed as they showed photographs saved on disc of their summer holiday in Tenerife, and of a weekend visit to Amsterdam etc. Work was continuing on reparation to the cracking of the plaster on the interior walls caused by subsidence. The structural reinforcement had been completed and most of the interior had been redecorated except for two bedrooms and the hall and stairwell. What the service does well: The home is good at ensuring the clients lead fulfilling lives by enabling them to attend local colleges for training and the development of skills and by seeking work experience opportunities for them in the community. Clients are encouraged to pursue their own hobbies and interests and are supported to access leisure activities and entertainment in the community. The home is good at ensuring the clients benefit from holidays, which they assist in planning and enjoy. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 A Statement of Purpose provides the information required about the service and all the clients had received a Service Users’ Guide appropriate to their needs. Records showed that individual client’s needs had been assessed prior a placement being offered to ensure their needs would be met. EVIDENCE: The Statement of Purpose includes all the information required in Schedule I of The Care Homes Regulations 2001. The name of the Commission for Social Care Inspections is referred to as The National Care Standards Commission and should be changed. Client’s files sampled showed that comprehensive assessments had been undertaken prior to a placement being offered. The manager had previously worked with some of the clients when they were younger and was very aware of their individual needs. He had been intent upon creating a peer group who would relate well to each other and have similar interests and abilities, he stated. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Please see the outcomes from the previous inspection. EVIDENCE: The key standards for this section had been assessed at the previous inspection therefore they were not reassessed. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, and 17 Clients are supported to live full and integrated lives in accordance with their wishes. They have access to appropriate leisure and cultural activities, maintain and develop personal relationships and are part of the local community. A varied and wholesome diet is offered to clients resulting in good health and enjoyment of life. EVIDENCE: The busy schedule of the clients of 33 Abbotswood included attending the College at Merrist Wood to take part in the Pathways to Horticulture course. There were photographs to show the clients receiving awards at the college. Another day was taken up with attendance at the Guildford College, the manager stated, and they do voluntary work at Hatchlands (National Trust) and at Hollycombe, where they tend the gardens, tracks, stables and paddocks and enjoy watching the trains. The clients took pleasure in showing the photographs of their social lives, which included a holiday in Tenerife, a weekend in Amsterdam and time spent in the company’s caravan in Pagham by the sea. One client was excited about the fact they had travelled to Holland by Eurostar and had seats on the top deck. Another client laughed as one of his peers said, ‘There’s a picture of you Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 11 with your girlfriend’. There was an abundance of photographs with images of happy young men attending football matches, dancing at discos, having special meals out, swimming, watching performing dolphins, enjoying the Chessington World of Adventure and taking trips on canal boats etc. A record was kept of all meals taken and the result was well balanced and appropriate. The clients usually have a light lunch, the manager stated and the main meal is in the evening. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18&19 Key workers offer individual support to clients and their preferences are taken into account. Regular health checks ensure clients physical health is maintained and the availability of an appropriate peer group, community interaction, the support of staff, who understand their needs and family involvement ensure the client’s emotional needs are also met. EVIDENCE: The clients are all reasonably independent as far as personal care is concerned, the manager stated, but they need prompts to remind them about teeth cleaning, taking the soap into the shower etc. All the bedrooms have en-suite shower and toilet facilities and the staff must be vigilant for, although seizures may be controlled to the greater extent, they may still occur so they knock on the shower room door and would enter in an emergency. When new clothing is needed, clients are taken out and enabled to choose, the manager stated, and he produced receipts and showed how the transactions were recorded. Records showed that the clients were registered with a General Practitioner and that all the regular health checks were completed. For evidence of how the client’s emotional needs are fulfilled please see the section headed, ‘Lifestyle’. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 13 A recommendation from the previous inspection was that the staff signatures should be recorded for identification on the MAR sheets. The staff signatures were viewed. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Clients can voice their opinions in meetings or in private to their key worker or to any member of staff of their choice. The complaints procedure should be revised to ensure the procedure followed complies with The Care Homes Regulations 2001. A local policy based on The Surrey Multi-Agency Adult Protection Procedures should be produced to inform the staff and to ensure that clients are protected. EVIDENCE: A complaints logbook was available but there were no complaints recorded. The complaints procedure should include a timescale for responding to the complainant to inform them of any action to be taken and the name of the Commission should be changed to The Commission for Social Care Inspection. The home held a copy of The Surrey Multi-Agency Adult Protection Procedures and the manager stated that he and the Responsible Individual had attended the training. Other staff, however, had not been successful in gaining bookings for this training, but efforts were being made rectify this, the manager stated. In the meantime it was important to ensure that the staff had a clear procedure and instructions to follow to protect clients. There had been no recorded instances of The Vulnerable Adults Procedures being instigated. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27&28 Despite contingency plans being in operation due to the re-plastering of the walls and ceilings of two client’s bedrooms, the accommodation was comfortable, bright, cheerful and homely and provided for the needs of the client’s appropriately. EVIDENCE: Work had been completed on the main shared spaces in the house and redecoration had taken place resulting in bright, airy and homely living accommodation. Contingency plans meant that the dining room would be a bedroom until the end of the week when the redecoration should be completed, the manager stated, and in the meantime the clients were using the large kitchen for meals. Two clients were sharing a bedroom until the end of the week when the redecoration would be completed, which was a choice they were happy about, the manager stated. The client’s bedrooms viewed were large and each was supplied with an ensuite shower, toilet and washing facility. The bedrooms were personalised with photographs, posters, pictures and items of special interest and showed that clients were encouraged to develop their individuality. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 16 There were plans to develop the garden to create a vegetable patch, with a greenhouse, fence off an area for playing ball games and make the area at the side of the house into a terraced space for relaxation, the manager stated. He was also aware that as soon as the improvement work was completed, that the car parking area would need to be cleared and resurfaced. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34&36 The staff personnel files were inaccessible and therefore key standard 35 will not have been assessed within the 12 month period. To ensure that safe recruitment practises are in operation to protect vulnerable adults it is essential that staff personnel files are available for inspection at all times. EVIDENCE: The staff personnel files were stored at the main office, the manager stated, and he tried unsuccessfully to contact the office to gain access to them. The regulations state clearly that the registered person should maintain these records in the care home and they must be available at all times for inspection by any person authorised by the Commission to enter and inspect the home, therefore a requirement will be made in respect of this standard. An example of a staff supervision record was viewed. It was signed and dated by both parties and appropriate. The diary showed that dates were booked for supervision sessions in keeping with the requirements. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38&40 The home is conducted in a manner, which respects and empowers the residents and results in enabling them to live full and happy lives. In order to ensure that the staff team are fully informed of all the homes policies and procedures to protect the clients there should be an acknowledgement that they have read them. EVIDENCE: The manager was still in the process of completing ‘The Registered Manager’s Award’ and staffing problems had hindered progress, he stated, but he is in the final stages and should complete in the early summer. The home is managed in an open and inclusive way, interactions between staff and clients were respectful and in conversations with the clients and the staff, it was clear that they felt valued. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 19 A sample of policies and procedures were viewed and there was no evidence that these had been read and understood by the staff. A signed record should be kept to verify the staff have read and understood them to ensure that staff follow the home’s procedures and understand the significance of them. Abbotswood (33) DS0000040846.V272919.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 1 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Abbotswood (33) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X X X DS0000040846.V272919.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA12 Regulation 20(1) Requirement The registered person must not pay money belonging to a client into a bank account unless it is in the name of the service user and request the local authority responsible to make alternative arrangements for payment of monies belonging to the said service user. This requirement will be carried forward as not completed. The registered person must ensure that the premises are of sound construction and are kept in a good state of repair internally and externally by providing a written confirmation of work completed to reinforce the structure of the home. This requirement will be carried forward as not completed. The registered person must ensure that all unnecessary risks to health and safety are identified and eliminated by the provision of a current gas safety certificate. This requirement will be carried forward as not seen. A copy should be sent to the CSCI local office. DS0000040846.V272919.R01.S.doc Timescale for action 12/01/06 2. YA24 23(2)(b) 12/01/06 3. YA42 13(4)(a) 12/12/05 Abbotswood (33) Version 5.0 Page 22 4. YA22 22(4) 5. YA23 13(6) 6. YA34 17(2)(b) The Registered Person must 12/01/06 ensure that the complaints procedure includes a timescale for responding to the complainant to inform them of the action to be taken. The Registered Person must 12/01/06 ensure that a local policy, which reflects The Surrey Multi-Agency Adult protection Procedures, be developed to inform the staff and protect the clients. The Registered Person must 12/12/05 ensure that staff personnel files are available for inspection at all times so that recruitment checks can be carried out for the protection of the clients. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA39 YA40 Good Practice Recommendations It was recommended by the inspector that the home conduct quality assurance monitoring. This recommendation is in process, but not completed. It is recommended that the Registered Manager ensures the staff have read and understood the home’s policies by signing when they have done so. 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